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INSULIN 101
Bedrija Nikocevic, PharmD, BCACP
Roosevelt University College of Science, Health and Pharmacy
DISCLOSURES AND CONFLICT OF INTEREST
• Bedrija Nikocevic declares no conflicts of interest, real or apparent, and no financial
interests in any company, product, or service mentioned in this program, including
grants, employment, gifts, stock holdings and honoraria.
PHARMACIST OBJECTIVES
At the conclusion of this program, the pharmacist will
be able to:
1. Describe steps to correctly prepare and
administer insulin
2. Select an appropriate syringe/needle based on
patient and therapy specific factors
3. Describe storage requirements for insulin
products
4. Discuss sharps disposal options.
TECHNICIAN OBJECTIVES
At the conclusion of this program, the technician will
be able to:
1. Describe how to calculate quantity and day supply
that accounts for correct use of injectable
diabetes therapies
2. Recognize situations involving insulin products
that should be referred to a pharmacist for
consultation
PRE-TEST QUESTION
How often should patients prime prefilled insulin pens?
A. The first time the pen is used
B. Every time the pen is used
C. Once a week
D. Once a month
PRE-TEST QUESTION
• KK is a 25 year old male who has been living with T1DM since age 4 years. He currently uses insulin glargine (Lantus) U-100 vial, 38 units QHS and insulin aspart (Novolog FlexPen) U-100 10 units TID. KK states he needs the ”shots” to administer Lantus and has plenty of all other supplies.
• Which of the following should you dispense?
A. BD Insulin Syringe 31 g 0.5 ml 6 mm
B. BD Insulin Syringe 31 g 0.3 ml 4 mm
C. Novofine Pen Needle 31 g 4 mm
D. Novofine Pen Needle 31 g 6 mm
PRE-TEST QUESTION
• Which of the following is an acceptable
household container to dispose sharps into?
A. Garbage can
B. Plastic water bottle
C. Glass mason jar
D. Plastic detergent bottle
INSULIN
INJECTABLE INSULIN
7.4 million Americans with diabetes use one or more formulations of insulin
In 2008, insulin accounted for 16% of all medication error events with reported harm
2010: most common medical errors in critical care patients were insulin administration errors
MARKETED INSULIN
PRODUCT FORMULATIONS
• Vial
• Pen
• Pump
• Inhaled insulin
MARKETED INSULIN
PRODUCT FORMULATIONS
Category Insulin Product Examples
Rapid
acting
Lispro U-100 vial: Admelog, Humalog, Lyumjev
U-100 pen: Admelog SoloStar, Humalog
KwikPen, Humalog Junior KwikPen, Lyumjev
KwikPen
U-200 pen: Humalog KwikPen, Lyumjev
KwikPen
Aspart U-100 vial: Fiasp, Novolog, Novolog ReliOn
U-100 cartridge: Fiasp PenFill, Novolog
PenFill
U-100 pen: Fiasp FlexTouch, Novolog
FlexPen, Novolog FlexPen ReliOn
Glulisine U-100 vial: Apidra
U-100 pen: Apidra SoloStar
Inhaled
insulin
Afrezza®: 4 units, 8 units, 12 units
https://labels.fda.gov/proprietaryname.cfm
MARKETED INSULIN PRODUCT FORMULATIONS
Category Insulin Product Examples
Short acting Human regular U-100 vial: Humulin R, Novolin R, Novolin R ReliOn
U-100 pen: Novolin R FlexPen, Novolin R FlexPen ReliOn
U-500 vial: Humulin R
U-500 pen: Humulin R KwikPen
Intermediate acting Human NPH U-100 vial: Humulin N, Novolin N, Novolin N ReliOn
U-100 pen: Humulin N KwikPen, Novolin N FlexPen, Novolin N FlexPen ReliOn
Long acting Detemir U-100 vial: Levemir
U-100 pen: Levemir FlexTouch
Glargine U-100 vial: Lantus, Semglee
U-100 pen: Basaglar KwikPen, Lantus SoloStar, Semglee
U-300 pen: Toujeo SoloStar, Toujeo Max Solostar
Degludec U-100 vial: Tresiba
U-100 pen: Tresiba FlexTouch
U-200 pen: Tresiba FlexTouch
https://labels.fda.gov/proprietaryname.cfm
MARKETED INSULIN PRODUCT FORMULATIONS
Category Insulin Product Examples
Premixed
insulin
Lispro
protamine/lispro
U-100 vial: Humalog Mix 50/50, Humalog Mix
75/25
U-100 pen: Humalog Mix 50/50 KwikPen,
Humalog Mix 75/25 KwikPen
Aspart
protamine/aspart
U-100 vial: Novolog Mix 70/30
U-100 pen: Novolog Mix 70/30 FlexPen
NPH/Regular U-100 vial: Humulin 70/30, Novolin 70/30
U-100 pen: Humulin 70/30 KwikPen, Novolin
70/30 FlexPen
https://labels.fda.gov/proprietaryname.cfm
PATIENT CASE
• JC is a 52 year old patient who was recently diagnosed with T2DM . He is presenting to your pharmacy today with a prescription for Lantus Solostar U-100, inject 10 units QHS as directed. Each SoloStar pen has 3 mL of insulin in it. How many pens will you need to dispense to JC if he needs a 28 days supply?
• ANSWER:
U-100 INSULIN SYRINGES
• 0.3 ml → 30 units
• ½ unit markings
• 1 unit markings
• 0.5 ml → 50 units
• 1 ml → 100 units
U-500 INSULIN SYRINGE
• 0.5 ml → 250 units
• 5 unit markings
• Use only with U-500 insulin
INSULIN PEN NEEDLES
Becton Dickinson. https://www.bd.com/en-us/offerings/capabilities/diabetes-care. Accessed July 27., 2021.
Novo nordisk. https://www.novoneedles.com/. Accessed July 27, 2021.
INSULIN INJECTION SITES
• Abdomen
• Back of upper arms
• Upper buttocks or hips
• Outer side of thighs
INSULIN VIAL INJECTION TECHNIQUE
• Gather supplies
• Re-suspend intermediate or premixed insulins
• Check insulin for lumps, crystals or discoloration
• Prepare insulin vial
• Pull air into syringe
• Inject air into vial
• Draw insulin
• Check for and expel air bubbles
• Prepare injection site
• Inject into skin at a 90 % angle, administer dose
• Wait 5-10 seconds before removing needle from skin
Needle length >6 mm:
Needle length 4-5 mm:
MIXING INSULINS
• Withdraw air for cloudy insulin
• Inject air into cloudy insulin; do not withdraw insulin yet
• Withdraw air for clear insulin
• Inject air into clear insulin and withdraw clear insulin
• Withdraw cloudy insulin
• Do not overdraw → cannot reinject insulin into vial
INSULIN PEN INJECTION TECHNIQUE
1. Gather supplies
2. Re-suspend intermediate or premixed insulins
3. Check insulin for lumps, crystals or discoloration
4. Wipe rubber seal with alcohol pad
5. Attach pen needle
1. Remove outer and inner cover
6. Prime with 2 units before each injection
7. Change needle if needed
8. Dial desired number of units
9. Inject into skin at a 90 % angle, administer dose
10. Wait 5-10 seconds before removing needle from skin
11. Recap needle with outer cover, remove and discard in sharps
12. *Use new needle each time*
13. *Do not store pen with needle attached*
RAPID ACTING INSULIN PEN DOSING
Insulin
Product
Unit
Increments
Max Units per
Dose
Repeat
Priming Steps
Admelog SoloStar 1 unit 80 units 3 times
Humalog KwikPen 1 unit 60 units 4 times
Humalog Junior
KwikPen
0.5 unit 30 units 4 times
Lyumjev KwikPen 1 unit 60 units 4 times
Fiasp FlexTouch 1 unit 80 units 6 times
Novolog FlexPen 1 unit 60 units 6 times
Apidra SoloStar 1 unit 80 units 2 times
https://labels.fda.gov/proprietaryname.cfm
SHORT AND INTERMEDIATE ACTING INSULIN PEN DOSING
Insulin Product Unit
Increments
Max Units per
Dose
Repeat
Priming Steps
Short Acting Insulin Products
Novolin R FlexPen 1 unit 60 units 6 times
Humulin R KwikPen
(U-500)
*use only for patients
who require >200
units of insulin/day*
5 unit
*prime with 5
units*
300 units 8 times
Intermediate Acting Insulin Products
Humulin N KwikPen 1 unit 60 units 4 times
Novolin N FlexPen 1 unit 60 units 6 timeshttps://labels.fda.gov/proprietaryname.cfm
LONG ACTING INSULIN PEN DOSING
Insulin
Product
Unit
Increments
Max Units per
Dose
Repeat
Priming Steps
Levemir FlexTouch 1 unit 80 units 6 times
Basaglar KwikPen 1 unit 80 units 4 times
Lantus SoloStar 1 unit 80 units 2 times
Semglee 1 unit 80 units 3 times
Toujeo Solostar 1 unit 80 units 3 times
Toujeo Max
Solostar
2 units 160 units 6 times
Tresiba FlexTouch
U-100
1 unit 80 units 6 times
Tresiba FlexTouch
U-200
2 units 160 units 6 times
https://labels.fda.gov/proprietaryname.cfm
PRE-MIXED INSULIN PEN DOSING
Insulin Products Unit
Increments
Max Units per
Dose
Repeat
Priming Steps
Humalog Mix 50/50
KwikPen
1 unit 60 units 4 times
Humalog Mix 75/25
KwikPen
1 unit 60 units 4 times
Novolog Mix 70/30
FlexPen
1 unit 60 units 6 times
Humulin 70/30
KwikPen
1 unit 60 units 4 times
Novolin 70/30
FlexPen
1 unit 60 units 6 times
https://labels.fda.gov/proprietaryname.cfm
INSULIN STORAGE GENERAL GUIDELINES
Never store pens with needle attached
Store away from direct heat and sunlight
Do not freeze insulin products
INSULIN STORAGE
Insulin Product Open Product Storage
Admelog Vial Fridge or room temp up to 28 days
Admelog Solostar Room temp up to 28 days
Humalog Vial Fridge or room temp up to 28 days
Humalog KwikPen Room temp up to 28 days
Lyumjev Vial Fridge or room temp up to 28 days
Lyumjev KwikPen Room temp up to 28 days
Fiasp Vial and
Fiasp FlexTouch
Fridge or room temp up to 28 days
Novolog Vial Fridge or room temp up to 28 days
Novolog FlexPen Room temp up to 28 days
Apidra Vial Fridge or room temp up to 28 days
Apidra SoloStar Room temp up to 28 days
https://labels.fda.gov/proprietaryname.cfm
INSULIN STORAGE
Insulin Product Open Product Storage
Humulin R U-100 Vial Fridge or room temp up to 31 days
Humulin R U-500 Vial Fridge or room temp up to 40 days
Humulin R U-500 KwikPen Room temp up to 28 days
Novolin R Vial Room temp up to 42 days
Novolin R FlexPen Room temp up to 28 days
Humulin N Vial Fridge or room temp up to 31 days
Humulin N KwikPen Room temp up to 14 days
Novolin N Vial Room temp up to 42 days
Novolin N FlexPen Room temp up to 28 days
https://labels.fda.gov/proprietaryname.cfm
INSULIN STORAGE
Insulin Product Open Product Storage
Levemir Vial Fridge or room temp up to 42 days
Levemir FlexTouch Room temp up to 42 days
Lantus Vial Fridge or room temp up to 28 days
Lantus SoloStar Room temp up to 28 days
Semglee Vial Fridge or room temp up to 28 days
Semglee Pen Room temp up to 28 days
Basaglar KwikPen Room temp up to 28 days
Toujeo/Toujeo Max SoloStar Room temp up to 56 days
Tresiba Vial Fridge or room temp up to 56 days
Tresiba FlexTouch Fridge or room temp up to 56 days
https://labels.fda.gov/proprietaryname.cfm
INSULIN STORAGE
Insulin Product Open Product Storage
Humalog Mix 50/50 Vial Fridge or room temp up to 28 days
Humalog Mix 50/50 KwikPen Room temp up to 10 days
Humalog Mix 75/25 Vial Fridge or room temp up to 28 days
Humalog Mix 75/25 KwikPen Room temp up to 10 days
Novolog Mix 70/30 Vial Fridge or room temp up to 28 days
Novolog Mix 70/30 FlexPen Room temp up to 14 days
Humulin 70/30 Vial Fridge or room temp up to 31 days
Humulin 70/30 KwikPen Room temp up to 10 days
Novolin 70/30 Vial Room temp up to 42 days
Novolin 70/30 FlexPen Room temp up to 28 days
https://labels.fda.gov/proprietaryname.cfm
SHARPS DISPOSAL
ILLINOIS
• Place in sharps container or in a heavy-plastic or metal container
• Secure the lid of household containers with heavy duty tape and write “Do Not Recycle” with permanent marker
• Do not place in recycle bin
• Do not overfill containers (3/4 full)
• Drop off collection sites
• Mail back programs
INSULIN USE ERRORS
INSULIN PRESCRIBING ERRORS
Writing U-500 insulin prescription with U-100 syringes
Missing Rxs for syringes/pen needles
Inappropriate syringe size selection
Rx for wrong insulin product
Prescribing only prandial or sliding scale insulin without basal
Wrong dose errors stemming from use of “do not use” abbreviations
Transcribing errors
https://www.ismp.org/alerts/severe-hyperglycemia-patients-incorrectly-using-insulin-pens-home. ACCESSED 7/28/2021
INSULIN DISPENSING ERRORS
Missing/inappropriate syringes or pen needles
Dispensing U-100 syringes with U-500 insulin
Incorrect insulin product
• Priming units
Incorrect day supply
PHARMACY TIMES. 10/23/2018.
ISMP. https://www.ismp.org/alerts/severe-hyperglycemia-patients-incorrectly-using-insulin-pens-home. ACCESSED 7/28/2021.
JOURNAL OF THE AMERICAN PHARMACISTS ASSOCIATION. 2020; 60: E76-E80.
INSULIN ADMINISTRATION ERRORS
Inaccurate injection site selection
Reusing needles
Failure to prime insulin pen
Injecting with capped needle
Relying on pen ”clicks” to determine appropriate dose
Improper injection technique
• Site rotation
• Skin pinching
• Twisting to ”0” instead of pressing plunger to inject
• Removing pen immediately after injection
Withdrawing U-500 insulin into a U-100 syringe for administration
INSULIN STORAGE ERRORS
Storing pens with needles on
Storing insulin pens in fridge while in use
Using insulin past discard date
PHARMACY TIMES. 10/23/2018.
ISMP. https://www.ismp.org/alerts/severe-hyperglycemia-patients-incorrectly-using-insulin-pens-home. ACCESSED 7/28/2021.
JOURNAL OF THE AMERICAN PHARMACISTS ASSOCIATION. 2020; 60: E76-E80.
QUESTIONS???
POST-TEST QUESTION #1
How often should patients prime prefilled insulin pens?
A. The first time the pen is used
B. Every time the pen is used
C. Once a week
D. Once a month
POST-TEST QUESTION #2
• KK is a 25 year old male who has been living with T1DM since age 4 years. He currently uses insulin glargine (Lantus) U-100 vial, 38 units QHS and insulin aspart (Novolog FlexPen) U-100, 10 units TID. KK states he needs the ”shots” to administer Lantus and has plenty of all other supplies.
• Part 1: Which of the following is appropriate to dispense?
A. BD Insulin Syringe 31 g 0.5 ml 6 mm
B. BD Insulin Syringe 31 g 0.3 ml 4 mm
C. Novofine Pen Needle 31 g 4 mm
D. Novofine Pen Needle 31 g 6 mm
POST-TEST QUESTION #2
• KK is a 25 year old male who has been living with T1DM since age 4 years. He currently uses insulin glargine (Lantus) U-100 vial, 38 units QHS and insulin aspart (Novolog FlexPen) U-100, 10 units TID. KK states he needs the ”shots” to administer Lantus and has plenty of all other supplies.
• Part 2: Which of the following is the correct day supply to bill KK’s insurance for the Lantus 100 unit/mL 10 mL vial?
A. 28 days
B. 30 days
C. 33 days
D. 26 days
POST-TEST QUESTION #4
• Which of the following is an acceptable household container to dispose sharps into?
A. Garbage can
B. Plastic water bottle
C. Glass mason jar
D. Plastic detergent bottle
TAKE HOME
POINTS
• There are numerous injectable diabetes medications and medication delivery devices, that all have unique features.
• The pharmacy team can play an integral role in helping people with diabetes achieve success in the use of injectable therapies and devices.
• Support patients, family members, significant others, and caregivers as they consider, initiate and learn how to optimize the use of injectable therapies and devices by
✓ Ensuring the accuracy of prescriptions and orders, order entry, insurance billing, and dispensing of diabetes therapies and devices.
✓ Assessing, identifying, and addressing barriers to optimal use,
✓ Staying up to date on diabetes therapies and technologies to provide ongoing patient training and education.
RESOURCES
Insulin injection and delivery
• https://www.bd.com/resource.aspx?IDX=11020&CMP=PIG
• https://www.diabeteseducator.org/practice/practice-tools/diabetes-management-tools/insulin-injection-resources2
• https://www.diabeteseducator.org/practice/practice-tools/diabetes-management-tools/ipt-resources
Sharps disposal
• https://safeneedledisposal.org/
• Illinois: https://safeneedledisposal.org/states/illinois/
REFERENCES
• Adlyxin [package insert]. Bridgewater, NJ: sanofi-aventis; 2021.
• Admelog [package insert]. Bridgewater, NJ: sanofi-aventis; 2020.
• American Diabetes Association. 7. Diabetes technology: Standards of Medical Care in Diabetes 2021. Diabetes Care 2021;44(Suppl. 1):S85–S99.
• Apidra [package insert]. Bridgewater, NJ: sanofi-aventis; 2019.
• Association of Diabetes Care and Education Specialists. Glucose monitoring: Insider tips and tricks. Available at https://www.diabeteseducator.org/docs/default-source/living-with-diabetes/tip-sheets/blood-glucose-monitoring/insidertipstricks-final.pdf?sfvrsn=14. Accessed July 31, 2021.
• Association of Diabetes Care and Education Specialists. Glucose monitoring recommendations. Available at https://www.diabeteseducator.org/docs/default-source/living-with-diabetes/tip-sheets/blood-glucose-monitoring/expertrecommendations-final9049dc36a05f68739c53ff0000b8561d.pdf?sfvrsn=14. Accessed July 31, 2021.
• Association of Diabetes Care and Education Specialists. (March 2021). Continuous subcutaneous insulin infusion (CSII) without and with sensor integration. Available at https://www.diabeteseducator.org/docs/default-source/default-document-library/continuous-subcutaneous-insulin-infusion-2018-v2.pdf?sfvrsn=4. Accessed July 31, 2021.
REFERENCES
• Association of Diabetes Care and Education Specialists and American Pharmacists Association Personal Continuous Glucose Monitoring Implementation Playbook. December 2020. Available at https://www.diabeteseducator.org/practice/practice-tools/app-resources/professional-cgm-playbook
• Basaglar [package insert]. Indianapolis, IN: Eli Lilly and Company; 2019.
• Berget C, Messer LH, Forlenza GP. A clinical overview of insulin pump therapy for the management of diabetes: Past, present, and future of intensive therapy. Diabetes Spectrum 2019;32:194-204.
• Bydureon BCISE [package insert]. Wilmington, DE; AstraZeneca Pharmaceuticals LP; 2021.
• Byetta [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; 2021.
• Fiasp [package insert]. Bridgewater, NJ: Novo Nordisk; 2020.
• Hinnen D. Glucagon-like peptide 1 receptor agonists for type 2 diabetes. Diabetes Spectrum. 2017;30(3):202-210.
• Hormone Health Network. "Continuous Glucose Monitoring: Connecting the Dots | Hormone Health Network." Hormone.org, Endocrine Society, 12 September 2021, https://www.hormone.org/support-and-resources/resource-library/cgm-connecting-the-dots
REFERENCES
• Humalog [package insert]. Indianapolis, IN: Eli Lilly and Company; 2019.
• Humulin N [package insert]. Indianapolis, IN: Eli Lilly and Company; 2019.
• Humulin R [package insert]. Indianapolis, IN: Eli Lilly and Company; 2019.
• Humulin R U-500 [package insert]. Indianapolis, IN: Eli Lilly and Company; 2019.
• Levemir. Prescribing information. Plainsboro, NJ: Novo Nordisk; 2020.
• Lantus [package insert]. Bridgewater, NJ: sanofi-aventis; 2021.
• Lyumjev [package insert]. Indianapolis, IN: Eli Lilly and Company; 2020.
• Messer LH, Berget C, Beatson C, Polsky S, Forlenza GP. Preserving skin integrity with chronic device use in diabetes. Diabetes Technol Ther. 2018;20(S2):S254-S264.
• Novolin N [package insert]. Plainsboro, NJ: Novo Nordisk; 2019.
• Novolin R [package insert]. Plainsboro, NJ: Novo Nordisk; 2019.
• Novolog [package insert]. Plainsboro, NJ: Novo Nordisk; 2021.
